Suzanne Jolley

Dual diagnoses of psychosis and drug or alcohol problems (DDp) are prevalent, high-cost presentations, reliably associated with poorer outcomes and greater difficulty engaging with mental health services compared to either condition alone or other mental health problems. Engagement difficulties restrict access to recommended care that could improve outcomes, and thus are a priority treatment target. Contingency management (financial incentives for positive health behaviours, CM), peer support, and text messaging each improve engagement for psychosis or drug/alcohol problems. Despite the high potential to improve engagement and thus clinical and economic outcomes in DDp, their combined impact remains unevaluated in this poorly treated and hard-to-reach population. We plan a confirmatory trial to test, for the first time, the impact on engagement in DDp of adding CM to usual care alongside text message reminders and peer support. Methodological innovation is required to ensure adequate rates of recruitment, retention, and outcome completion; as well as standardised delivery of interventions, particularly CM, which will be delivered by peer support workers, and will target attendance, to improve engagement in recommended treatments. We comment here on the protocol for CoMPEERS (ISRCTN90137206), a study to test the feasibility of progressing this novel design to a full trial.

Purpose: It is a half‐century since the coalescence of social psychiatry and systemic family therapy approaches started to inform condition‐specific therapeutic work with families to reduce relapse and hospital readmission for people with schizophrenia. Today, family interventions are a cornerstone of international guidelines for the treatment of psychosis, and of workforce development initiatives. Effect sizes for clinical and economic outcomes are large, and the evidence base is robust and reliable, not only for outcomes but also for the underpinning theoretical models, which are coherent and consistent. Few, if any, psychological therapies, have so powerful a framework to drive widespread implementation. Nevertheless, delivery in clinical services is variable, often lagging behind that of individual cognitive behavioural therapy, notwithstanding its considerably weaker implementation framework. Our aim in this article is to formulate this translation failure and offer potential solutions. Method: We summarise the model/intervention and supporting evidence, then consider why delivery remains problematic. Results: We highlight the inter‐linked issues of conceptual confusion between and conflation of, different approaches to working with families; of addressing diagnostic uncertainty, complex comorbidity and adapting interventions for specific populations; and of translation from gold‐standard research trial practice, through educational curricula and training programmes, to routine delivery in frontline services. Conclusion: We present our view of clinical, research and workforce development priorities to address these issues and continue the collective effort, moving into the next half‐century, to work more effectively with people with psychosis and their families, to further improve outcomes.

Background: Around 10% of school-aged children experience mental health difficulties. Many more are ‘vulnerable’: experiencing emotional and/or behavioural problems reaching clinical levels, and thus at greatest risk of future mental illness. The trial aim is to evaluate the effectiveness of the CUES for schools programme in reducing emotional and behavioural problems in vulnerable children. Methods: The “CUES for Schools” study is a multicentre cluster randomised controlled trial in primary schools in south east England. Schools will be randomised to receive the usual school curriculum, or the CUES programme (1:1). We aim to enrol 74 schools (5550 children including 2220 vulnerable children). CUES is a whole-class teacher-facilitated interactive digital cognitive-behavioural intervention, delivered as 24 short (20-min) modules over 12 weeks, targeting emotional/behavioural regulation skills. Children self-report emotional/behavioural problems at baseline, 8, and 16 weeks, and wellbeing and cognitive vulnerability at 0 and 16 weeks. Adverse events are assessed at 8 and 16 weeks. Teachers rate classroom behaviour at baseline and 16 weeks. School senior leadership teams and individual teachers consent to involvement in the study; parents can opt their child out of CUES sessions, assessments, or research. Children can similarly opt out and assent to research participation. The primary objective of this trial is to evaluate the effectiveness of CUES for schools compared to the usual school curriculum in improving emotional/behavioural problems for vulnerable Year 4 (8–9 years old) children at 16 weeks post-randomisation, as measured using a standardised questionnaire designed for primary schools. The secondary objective is to investigate the impact of the CUES for schools programme on both vulnerable and non-vulnerable children on wellbeing and teacher-rated classroom behaviour. Discussion: The study will show whether CUES for schools is more effective than the usual curriculum in reducing emotional and behavioural problems in vulnerable Year 4 children, and thus reducing the risk of mental health difficulties in later adolescent and adult life. As a digital, teacher-facilitated intervention, CUES for schools can be readily implemented, at minimal cost. If effective, CUES for schools therefore has the potential to reduce the impact of emotional/behavioural difficulties on children’s learning, behaviour, and relationships and the burden of future mental health morbidity. Trial registration: Trial Registration ISRCTN11445338. Registered on September 12, 2022.

Objectives: Individuals with psychosis report that emotion regulation (ER) difficulties are treatment priorities, yet little is known about how targeted ER interventions may help. We evaluated a new eight‐session Dialectical Behavioural Therapy (DBT)–informed skills group specifically adapted for individuals with psychosis: the Managing Emotions Group (MEG) in diverse, inner‐city community services. Method: A mixed‐method design was utilised to assess the feasibility (acceptability and potential clinical impact) of local delivery of MEG. Uptake, completion (≥50% of sessions), post‐session satisfaction ratings, and thematic analysis of qualitative feedback from 12 completers assessed acceptability. Pre–post‐intervention changes in psychological distress, self‐reported ER difficulties, and adaptive ER skill use assessed potential clinical impact. Results: Forty‐eight individuals (81% of attenders) completed the intervention ( M _age = 43, 54% female) of whom 39 completed pre‐ and post‐group measures. Participants reported high satisfaction and meaningful improvements in understanding and managing emotions, with positive impact on daily life. Self‐reported psychological distress, ER difficulties, and adaptive ER skill use significantly improved, with medium‐to‐large pre‐post effects ( d = 0.5–0.7) except lack of emotional clarity ( d = 0.3). Conclusions: MEG was feasible and acceptable, and a future feasibility randomised controlled trial is warranted. Practitioner points: Individuals with psychosis report that support with their emotions is a priority. Brief interventions for emotion regulation difficulties are acceptable to individuals with psychosis and can be feasibly delivered in a local outpatient service. Distress and emotion regulation difficulties and skills improved significantly from pre–post treatment for clients completing the managing emotions group. Further implementation and evaluation are needed to support continued refinement to meet the needs and priorities of individuals with psychosis.

Purpose: Neurocognitive difficulties and early childhood speech/motor delays are well documented amongst older adolescents and young adults considered at risk for psychosis-spectrum diagnoses. We aimed to test associations between unusual or psychotic-like experiences (PLEs), co-occurring distress/emotional symptoms, current cognitive functioning and developmental delays/difficulties in young people (aged 8–18 years) referred to Child and Adolescent Mental Health Services in South London, UK. Methods: Study 1 examined receptive language, verbal learning and caregiver-reported speech and motor delays/difficulties in a sample of 101 clinically-referred children aged 8–14 years, comparing those reporting no PLEs (n = 19), PLEs without distress (n = 16), and PLEs with distress (n = 66). Study 2 tested associations of severity of distressing PLEs with vocabulary, perceptual reasoning, word reading and developmental delays/difficulties in a second sample of 122 adolescents aged 12–18 years with distressing PLEs. Results: In Study 1, children with distressing PLEs had lower receptive language and delayed recall and higher rates of developmental delays/difficulties than the no-PLE and non-distressing PLE groups (F values: 2.3–2.8; p values: < 0.005). Receptive language (β = 0.24, p = 0.03) and delayed recall (β = − 0.17, p = 0.02) predicted PLE distress severity. In Study 2, the cognitive-developmental variables did not significantly predict PLE distress severity (β values = 0.01–0.22, p values: > 0.05). Conclusion: Findings may be consistent with a cognitive-developmental model relating distressing PLEs in youth with difficulties in cognitive functioning. This highlights the potential utility of adjunctive cognitive strategies which target mechanisms associated with PLE distress. These could be included in cognitive-behavioural interventions offered prior to the development of an at-risk mental state in mental health, educational or public health settings.

Objective: Individuals with psychosis self‐report difficulties in understanding, relating, and responding to emotions as treatment priorities, yet we lack comprehensive, reliable, and valid assessments for routine clinical use.Methods: The psychometric properties of a brief version of the Difficulties in Emotion Regulation Scale‐16 (DERS‐16) were examined using anonymized data from a sample of 150 outpatients with psychosis.Results: Confirmatory factor analysis supported the five‐factor structure of the DERS‐16. The model fit was further improved by omitting two items. Measurement invariance was shown with respect to age and gender. The DERS‐16 demonstrated good internal consistency, well comparable to the original DERS. Evidence toward convergent validity is also presented.Conclusion: Findings suggest that the DERS‐16 is a reliable and valid measure of self‐reported emotion regulation difficulties in individuals with psychosis. Further research on the clinical utility of the DERS‐16 is needed, including examination of its test–retest reliability and predictive validity in response to targeted interventions.

Objective: Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G‐ACTp), delivered by frontline staff, and co‐facilitated by service‐user experts‐by‐experience (SU‐EbyE), for service‐users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation. Methods: Staff and SU‐EbyE facilitators completed 1‐day workshops, then delivered closely supervised G‐ACTp, comprising four sessions (weeks 1–4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G‐ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service‐use/month was calculated for 1‐year pre‐randomization, weeks 0–12, and 5‐year uncontrolled follow‐up. Results: Of 41 facilitators trained (29 staff, 12 SU‐EbyE), 29 (71%; 17 staff, 12 SU‐EbyE) delivered 18 G‐ACTp courses. Participant refusal rates were low (9% of service‐users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G‐ACTp session (64% of service‐users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow‐up was incomplete (78% [66/85]; 82% of service‐users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service‐use reductions require cautious interpretation, as very few participants incurred costs. Conclusions: Implementation appears feasible for service‐users; for caregivers, retention needs improving. Outcome variability indicated n = 100–300/arm followed up (α = 0.05, 90% power). Methodological limitations’ mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion. Practitioner points: Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

Emotions play a key role in the development and experience of psychosis, yet there are important gaps in our understanding of how individuals with psychosis understand and respond to their emotions. This systematic review investigated self‐reported emotion regulation difficulties in individuals with psychosis compared with non‐clinical controls. An electronic database search was conducted in Medline, PsychINFO, and Embase and supplemented by searches of reference lists and citations. Seventeen studies were included. A narrative synthesis was conducted because contextual diversity was present across the studies and outcomes. Individuals with psychosis reported greater difficulties in (i) emotional clarity (specifically with identifying, describing, and understanding their emotions), (ii) emotional acceptance, (iii) engaging in goal‐directed behaviours when experiencing negative emotions, and (iv) willingness to experience emotional distress in the pursuit of meaningful activities in life. Evidence pertaining to other self‐reported emotion regulation difficulties was less clear. Effect sizes were generally large in magnitude but there were few studies on some self‐reported emotion regulation difficulties, and all studies were at moderate to high risk of bias. Further research is needed to clarify the nature of emotion regulation difficulties in individuals with psychosis to inform the provision of targeted clinical interventions.